Every finding on record at Cross Timbers Hospice, Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to assess the patient's pain.. The nurse surveyor observed in HOSRRHV #2 the RN failed to complete a pain assessment per the Agencies Pain Assessment Policy 2-031 that included the location, duration, severity, and what makes the pain better or worse. This was reviewed and validated by the Patient Care Coordinator.

Observed in Record Review. In 9 of 14 patient records reviewed, the organization failed to accurately notify the patient of their right to choose their medical provider. In HOSRRHV #1 the patient did not select whether they wanted another provider or the hospice medical director the section was left blank. In HOSRRHV #4, HOSRRNHV #1, HOSRRNHV #2, HOSRRNHV #3, HOSRRNHV #4, HOSRRNHV #7, HOSRRNHV #8, and HOSRRNHV #10 this section was left blank as well. This was reviewed and validated with the Patient Care Coordinator.

Observed in Regulatory Review. In 1 of 14 patient records reviewed, the chaplain failed to complete his initial assessment within five days after the election of hospice. The hospice surveyor observed that in HOSRRNHV #10 the chaplain assessment was completed on day 26 after the election of benefit. This was reviewed and validated with the Patient Care Coordinator.

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice surveyor observed in record review in HOSRRHV #2 where the pain assessment was not completed in the comprehensive assessment at admission. The RN did not enter the quality of pain, duration, what makes the pain better or worse. The organization's Comprehensive Assessment Policy 2-029 states that a complete pain assessment must be entered at admission. This was reviewed and validated by the Patient Care Coordinator.

Observed in Record Review. In 3 of 17 patient records reviewed, the bereavement assessment was not completed by the social worker, as required by policy. The hospice surveyor observed in HOSRRNHV #10 the social worker did not complete a bereavement assessment on the patient's brother. In HOSRRBRV #1 the social worker did not complete a bereavement assessment on the two adult sons in the home and the cousin who is also the caregiver. In HOSRRBRV #2 the social worker did not complete a bereavement assessment on the patient's father. The social worker documented in November and December that the patient was at the father's home. Per the organizational policy Bereavement Services 2-009 the program will provide bereavement services to the family and caregiver of hospice patients. This was reviewed and validated with the Bereavement Coordinator.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to assess the need for volunteer services. The hospice surveyor noted that in HOSRRHV #1, HOSRRHV #2, HOSRRHV #3, and HOSRRHV #4, HOSRRNHV #1, HOSRRNHV #2, HOSRRNHV #3, HOSRRNHV #4 HOSRRNHV #5, HOSRRNHV #6, HOSRRNHV #7, HOSRRNHV #8, HOSRRNHV #9, HOSRRNHV #10 the need for volunteer services was not assessed. This was reviewed and validated with the Patient Care Coordinator.

Observed in Record Review. In 8 of 14 patient records reviewed, the hospice surveyor observed where the nursing, MSW, and chaplain care plans are not individualized and specific to the patient needs. In HOSRRHV #1 and HOSRRNHV #1, HOSRRNHV #8 the nursing care plan stated, Patient safety needs AEB changes are made as needed to assure safety needs are met. It is not clear what the safety needs are and how they will be met. In HOSRRHV #1 the Chaplain care plan stated, Pt to express a sense of acceptance and peace regarding changing circumstances. It is not clear what sense of peace would be for the patient. In HOSRRNHV #1 the nursing care plan stated, Care needs met AEB patient voices care needs met. It is not clear what specific care needs the patient has. In HOSRRNHV #2, HOSRRNHV #7 and HOSRRNHV #10 the MSW care plan stated, Patient will adjust to changes and changing physical conditions and will express feelings of being supportive. It is not clear what the conditions are that the MSW is going to help the patients and families address. In HOSRRNHV #3 the chaplain care plan stated, Patient and family utilize chaplain to provide spiritual support. It is not clear what spiritual support the patient or family may need. In HOSRRNHV #9 the MSW care plan stated, Patient and family will express feeling emotionally supported by SW as they cope with the psychosocial aspect of disease process. It is not clear what psychosocial aspects of the disease process the MSW will assist the patient with. The Chaplain care plan stated, Chaplain services to provide spiritual and emotional support, not specific what type of emotional support he will be providing. This was reviewed and validated with the Patient Care Coordinator. Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to plan the patient's care. The hospice surveyor observed in HOSRRNHV #1 where the patient had an acceptable level of pain as 0 and the RN entered a care plan that stated Patient will experience pain relief and control AEB patient rates pain at 4 or less. In HOSRRNHV #2 the patient was assessed for an acceptable level of pain and it was 0 and the nurse entered the care plan, Patient will experience pain relief and control AEB patient rates pain at 3 or less. In HOSRRNHV #3 the patient's acceptable level of pain control was not assessed and the care plan for pain states, Patient will experience pain relief and control AEB patient denies pain and rates 3 or less. In HOSRRNHV #5 the nurse used a verbal tool to assess the patient's pain but the nurse documented using the Edmonton Symptom assessment System in the care plan. He documented the wrong scale in the care plan for pain, In HOSRRNHV #7 the nurse used the PAINAD scale as the patient has a diagnosis of Alzheimer's. In the care plan for pain the nurse documented that the FACES scale was used. These care plans do not align with the patient's pain goal. This was reviewed and validated with the Patient Care Coordinator.

Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to plan the patient's care. The hospice surveyor observed in HOSRRHV #4 where the RN documented in IDT notes that the patient had a fungal rash underneath her left breast and that it would be treated with antifungal powder daily. No care plan was entered for this problem. In HOSNHV#3 the patient had Nystatin powder on the medication list for chaffing under both breasts. The care plans did not include this as a problem or goal. In HOSRRNHV #5 the patient had a diagnosis of respiratory failure but no care plan was entered. In HOSRRNHV #7 the patient was on ASA and Plavix and there was no care plan for bleeding precautions. In HOSRRNHV #10 the patient was on 4 different medications for constipation and there was no care plan entered for constipation.. This was reviewed and validated with the Patient Care Coordinator.

Observed in Record Review. In 6 of 14 patient records reviewed, the hospice surveyor observed in HOSRRHV #1 the patient had duplicate medications for anxiety. The patient had Lorazepam 0.5 mg QHS, Lorazepam 0.5 mg every six hours as needed for anxiety, and Lorazepam 0.25 ml buccal every 6 hours and as needed. It is not clear which of the medications the patient should take for anxiety. This patient also had duplicate medications to treat constipation. There were orders and the bottle stated, for a stool softener 100 mg twice a day, Dulcolax 5 mg daily and as needed, and Senna one tab twice a day and as needed. It is not clear which of the medications the patient should take for constipation. In HOSRRHV #2 the patient had Norco 5-325 mg 1 tablet by mouth every 6 hours and as needed for break through pain, and Roxidone 15 mg every 4 hours and as needed for breakthrough pain. It is not clear which one should be taken for breakthrough pain. This patient also had orders for Phenergan 25 mg every 6 hours and as needed for nausea and Zofran 4 mg every 4-6 hours and as needed for nausea. In HOSRRNHV #4 the patient was on Colace 20 ml by peg tube twice a day, Senna 8.6 mg twice a day in am and pm, Senna Plus 8.6 mg one dime a day and adjust to 1-4 times as needed, and Dulcolax 10 mg rectal suppository every 72 hours and prn. There are no parameters for when one should be taken over the other. This patient also had duplicate orders for Tramadol 50 mg two times a day oral for severe pain and Tramadol 50 mg 1/2 tablet by mouth every 6 hours and prn for severe pain. For anxiety this patient had Atarax 25 mg 2 pills orally as needed and Ativan 0.5 mg orally every 3 hours prn. In HOSRRNHV #5 the patient was on Methadone 2.5 mg by mouth twice a day for severe pain and Advil 200 mg every 4 to 6 hours and as needed for severe pain. It is not clear which one should be taken for severe pain. n HOSRRNHV #6 the patient was on Phenergan 25 mg every 6 hours for nausea and Zofran 4 mg 2 tablets every 4 hours for nausea. It is not clear wen the patient should take one of the medications over the other. In HOSRRNHV #10 the patient was on MiraLAX 17 gm in 8 ounces of fluid one time a day and prn, MOM 30 mg daily and as needed, Bisacodyl suppository daily as needed for constipation. There were no clear parameters of when to take one over the other. This was reviewed and validated with the Patient Care Coordinator. Observed in Patient Home. In 6 of 14 patient records reviewed, the organization failed to accurately document medications. In HOSRRHV #1 and HOSRRNHV #1 the patient had an order for Oxygen 2-4 liters continuous via nasal cannula. The RN failed to document when the patient should use 2, 3, or 4 liters. In HOSRRNHV #5 the patient had an order for Oxygen 4-5 liters. The RN failed to document when the patient should use 4 or 5 liters. In HOSRRNHV #8 the patient had an order for Oxygen 6-10 liters. The RN failed to document when the patient should use 6, 7, 8, 9, or 10 liters. In HOSRRNHV #9 and HOSRRNHV #10 the patient had an order for Oxygen 1-5 liters. The RN failed to document when the patient should use 1, 2, 3, 4, or 5 liters. This was reviewed and validated with the Patient Care Coordinator.

Observed in Tracer Activities. The organization failed to analyze and trend their QAPI data. The hospice surveyor observed that the organization collected data on quality metrics such as timeliness of completion of the comprehensive assessment, hand hygiene, and falls but none of the data was trended over time or analyzed for process improvement. This was reviewed and validated with the Administrator and the Compliance Director.

Observed in Tracer Activities. The hospice surveyor observed during tracer activity that the organization did not have measurable goals and no specific performance improvement project was derived from their data. The organization failed to show any improvement in data that was collected. This was reviewed and validated by the Administrator and Compliance Director.

Observed in Tracer Activities. The hospice surveyor observed during tracer activity that the organization failed to improve performance on many of their indicators. There were no specific process improvement projects completed and thus no process improvement noted in the indicators selected. This was reviewed and validated with the Administrator and Compliance Director.

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice surveyor observed in HOSRRNHV #2 that the patient was diagnosed with an Urinary MDRO and there was no evidence that the organization had established a process for identifying individuals or instituted appropriate transmission based precautions. This was reviewed and validated with the Patient Care Coordinator.

Observed in Patient Home. In 7 of 14 patient records reviewed, the home health aide failed to provide care, treatment or services for the patient. In HOSRRHV #1, HOSRRNHV #1, HOSRRNHV #5, HOSRRNHV #8, HOSRRNHV #9, and HOSRRNHV #10 the patients were on continuous Oxygen and there were no instructions for the aide in the aide flowsheet plan as to what she should do with the oxygen when bathing the patient. These patients also had a range for liter flows and the aide flowsheet did not contain the appropriate liter flow for the patient. Additionally, all of these patients had barrier cream in the flowsheet to be applied but there were no directions as to the location where it should be applied. The nurse surveyor observed during the home visit in HOSRRHV #4 where the aide flowsheet plan stated that the aide would provide the patient oral care, nail care, skin/back care, and barrier cream with each visit. The aide did not offer or provide any of these services and the barrier cream did not have a location as to where it should be applied. The hospice surveyor asked the home health aide about the barrier cream and she was unaware of what it was for. This patient also had a wound to her left breast and a fungal infection underneath her left breast. There were no instructions in the aide flowsheet plan as to what she should do with the site during the shower. After the shower the aide sprinkled antifungal powder underneath the left breast. This was reviewed and validated with the Patient Care Coordinator. Observed in Record Review. In 10 of 14 patient records reviewed, the organization failed to individualize the patient's care. The hospice surveyor observed in HOSRRHV #1, HOSRRHV #2, HOSRRHV #4, HOSRRNHV #3, HOSRRNHV #5, HOSRRNHV #7, HOSRRNHV #8, HOSRRNHV #9, HOSRRNHV #10, where under Observations Reported to the Nurse there is templated language for the aide to report difficulty swallowing or eating and seizures and none of these patients had a diagnosis or issues. This language was found in all of the aide assignment sheets. This was reviewed and validated with the Patient Care Coordinator.

Observed in Patient Home. In 1 of 4 HR files reviewed, the home health aide failed to follow the plan of care. In HOSRRHV #4 the hospice surveyor observed that the home health aide did not perform peri care per the aide flowsheet. She gave the patient a hand towel with soap and the patient cleaned herself in the front only. This patient is incontinent of bladder and when the aide was assisting her to put on her diaper she gave the patient an incontinent pad to place in the diaper and then she assisted the patient with placing toilet paper on top of the incontinent pad. Applying the toilet paper was not in the aide flowsheet that was developed by the RN. This was reviewed and validated with the Patient Care Coordinator.

Observed in Patient Home. In 3 of 4 home visits conducted, the hospice surveyor observed that the medication list in the home was inaccurate. In HOSRRHV #2 the medication list stated that the patient was taking Losartan 50 mg one time per day. On the medication bottle it states that the patient is to take the medication twice a day. The patient had timolol maleate 1 drop per eye on the medication list but the medication box states that the medication is Dorzolamide HCL Timolol maleate. In HOSRRHV #3 the medication list states Hydrochlorothiazide 25 mg per day but the medication bottle states 12.5 mg per day. The Pantoprazole on the medication list states 40 mg one time a day but the medication bottle states 20 mg per day. This patient also was taking Docusate Sodium 100 mg QHS which was not on the medication list. Per the patient's daughter the patient has been on these medications for months. In HOSRRHV #4 the patient states that she is using asper cream topical ointment for her arthritis to her left heel. This was not included in the medication list. This was reviewed and validated with the Patient Care Coordinator.

Observed in Record Review. In 1 of 2 patient records reviewed, the deemed hospice agency did not provide the community physician with the discharge summary after discharge to the community. In HOSRRDC #2 the organization failed to send the community provider a discharge summary per the organizational policy Discharge from Hospice Program 2-009. This was reviewed and validated with the Patient Care Coordinator.

Observed in Record Review. In 1 of 7 active patient records reviewed, During RR# 8's patient record review it was noted the registered nurse had not completed a pain assessment per the organization's Pain Assessment policy #2-031. For example: review of RR# 8's patient record revealed a SN visit note with documentation RR# 8 had a pain level of 10 out 10. Further review of the SN visit note revealed no documentation of pain quality, pain onset, duration, variations and patterns; alleviating and aggravating factors; and patient's acceptable level of pain as required by policy. This was reviewed, discussed, and validated with Patient Care Coordinator.

Observed in Record Review. In 2 of 2 active patient records reviewed with wounds, During RR# 7 and RR# 10's patient records review it was noted the organization had not ensured it assessed and reassessed its patients. For example: review of RR# 7's patient record revealed RR# 7 was admitted with a stage II right buttock pressure ulcer. Further review of the record revealed the wound was not measured weekly as required by the organization and the last documented wound assessment was completed 101 days prior to the survey review of the record. Review of RR #10's patient record revealed two wounds on admission. Further review of the record revealed the wounds were not assessed weekly and the last documented wound assessment was completed on admission or 43 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Patient Care Coordinator.

Observed in Record Review. In 3 of 7 active patient records reviewed, during HV# 2, RR# 7, and RR# 8's patient records review it was noted the organization had not ensured the patient's plan of care was based on the patient's goals and time frames, settings, and services required to meet those goals. For example: review of RR# 8's patient record revealed documentation that RR# 8 had stated pain from 7 out of 10 to 10 out of 10. Further review of RR# 8's patient record revealed documentation that RR# 8's stated an acceptable pain level was 3 out of 10. Review RR# 8's plan of care revealed a pain goal of 8 out of 10. Review of HV# 2's plan of care revealed the goal for patient and family, achieve regular bowel function w/o [without] s/s [signs and symptoms] complication. However, there was no indication what a regular bowel function would be for HV# 2. Further review of HV# 2's plan of care revealed the goal For patient, experience pain relief/control. However, there was no documentation on what pain relief/control would be for HV# 2. Review of RR# 7's plan of care revealed the goal Patient and Family, achieve optimal fluid/electrolyte balance. However, there was no documentation on what fluid electrolyte balance would be for RR# 7. This was reviewed, discussed, and validated with the Patient Care Coordinator.

Observed in Record Review. In 5 of 7 active patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 7, and RR# 9's patient records review it was noted the organization had not ensured the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: HV# 2's plan of care did not include safety precautions such as bleeding when on an anticoagulant and fall precautions with an assessed fall risk. In addition, HV# 1's plan of care did not include safety precautions such as fall precautions with an assessed fall risk. HV# 3's plan of care did not include safety precautions such as oxygen safety precautions when patient on oxygen. RR# 7's plan of care did not include oxygen safety precautions when patient on oxygen. RR# 9's plan of care did not include safety precautions such as bleeding when on an anticoagulant. This was reviewed, discussed, and validated with the Patient Care Coordinator.

Observed in Record Review. In 2 of 7 active patient records reviewed, During HV# 3 and RR# 7's patient record review it was noted the organization had not ensured the plan of care included all the services needed for palliation and management of the terminal illness and related conditions including medications and treatments necessary to meet the patient's needs. For example: review of HV# 3's plan of care revealed an order for oxygen using concentrate at 4 L with no documentation on how the oxygen would be administered. Review of RR# 7's plan of care revealed an oxygen order for oxygen-air delivery system (device) by nasal as directed as needed, with no additional information regarding how much oxygen and how the oxygen would be delivered. This was reviewed, discussed, and validated with the Patient Care Coordinator.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 1 and HV# 2 it was noted the organization had not ensured care, treatment, or services were provided according to the plan of Care. For example: during HV# 1's home observation the registered nurse (RN) did not perform a skin assessment as required by the plan of care. During HV# 2's home observation the Licensed Practical Nurse (LPN) did not perform a skin assessment as required by the plan of care. This was observed, discussed, and validated with the Patient Care Coordinator.  Observed in Record Review. In 1 of 8 active patient records reviewed, During HV# 3's patient record it was noted the organization had not ensured it provided patient care, treatment, or services according to the patient's individualized plan of care. For example: review of HV# 3's patient record revealed HV# 3 had a supra pubic catheter with a standing order change the supra public catheter every 30 days and as needed. Review of HV# 3's patient record revealed the last supra pubic catheter was changed was 53 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Patient Care Coordinator.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 1 and HV# 2's home observations it was noted that the staff failed to perform hand hygiene consistent with the organization's Hand Hygiene policy that included performing hand hygiene after removing gloves and after providing patient care or touching inanimate objects. For example: during HV# 1's home observation the registered nurse was observed removing her gloves and putting on new gloves without performing hand hygiene. During HV# 2's home observation the Licensed Practical Nurse (LPN) was observed wearing the same pair of gloves to perform a B/P reading and clean the B/P cuff with a Sani-cloth; document the B/P reading; complete a pulse oximetry reading and clean the pulse oximetry with a Sani-cloth; document the pulse oximetry reading; listened to HV# 1's chest and abdomen; and clean the stethoscope with a Sani-cloth. This was observed, reviewed, discussed, and validated with the Patient Care Coordinator. Observed in Patient Home. In 1 of 2 home visits conducted with a bag, During HV# 1's home observation it was noted the organization had not ensured the organization's Bag Technique policy that included performing hand hygiene prior to entering the bag was followed. During HV# 1's home observation the registered nurse (RN) was observed entering the bag without performing hand hygiene prior to entering the bag. This was observed, reviewed, and discussed with the Patient Care Coordinator and validated.

Observed in Record Review. In 6 of 6 active patient records with Home Health Aide services, During HV# 1, HV# 2, HV# 3, RR# 7, RR# 9, and RR# 10's patient records review it was noted the registered nurse did not prepare specific written patient care instructions for the aide. For example: during review of the aide written instructions for HV #1, HV# 2, HV# 3, RR# 7, RR# 9, and RR# 10 revealed the task of vital signs; however, did not specify the parameters for the aide to notify the registered nurse for the blood pressure reading, respirations, and heart rate. In addition, review of HV# 1's patient record revealed HV# 1 had a supra public catheter and on continuous oxygen. Review of the aide written instructions on start of care revealed no documentation on whether the oxygen should be removed with a shower or that HV# 1 had a supra pubic catheter. Review of RR# 7's patient record revealed RR# 7 has a stage II pressure ulcer on the right buttock. However, review of the aide written instructions revealed no documentation RR# 7 had an open wound. Review of RR# 9's patient record revealed RR# 9 had a PEG tube. However, review of the aide written instructions revealed no documentation regarding a PEG tube. Review of RR# 10's patient record revealed RR# 10 had and open wound to the left shin area. However, review of the aide written instructions revealed no documentation RR# 10 had a wound. This was reviewed, discussed, and validated by the Patient Care Coordinator.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and §418.116

Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 3's home observation it was noted the organization had not ensured it maintained the security and integrity of the patient record. For example: review of the Consent and Medicare Election of Benefit forms revealed information was added to the forms after the patient representative signed and dated the form. The Consent and Medicare Election of Benefit revealed no signature or dates from the hospice representative and no documented date on the election of benefit date line. However, review of the forms in the patient record revealed the election of benefit date and the hospice representative signature and date were documented. This was reviewed, discussed, and validated with the Patient Care Coordinator.

Observed in Record Review. In 3 of 3 discharged records reviewed for extended prognosis, During RR# 2, RR# 5, and RR# 6's patient records reviewed it was noted the organization had not ensured it had a process in place to ensure the Notice of Medicare Non-Coverage (NOMNC) was signed within 2 days of discharge from Medicare. For example: review of RR# 2's NOMNC form revealed RR# 2's signature one day after the date of discharge from Medicare. Review of RR# 5's NOMNC revealed RR# 5's signature 13 days after the date of discharge from Medicare. Review of RR# 6's NOMNC form revealed RR# 6's signature the same day as the date of discharge from Medicare. This was reviewed, discussed, and validated with the Patient Care Coordinator.